Nutrition made critical.

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Again, in 3-part harmony–it’s not about “the science”

Let me be straight. I don’t believe in conspiracy theories.* There’s no Bacon-gate. No Cowspiracy. No Salami-mafia out to suppress sandwich meat. But, as the students in my Introduction to Science, Technology, and Society course will tell you, there are professional interests (only one of which is funding) and careerism. There is also the human desire to simply not be wrong. In nutrition, this desire is personal.

(If I were queen of the world, every research article published about nutrition and chronic disease would list, in addition to “author affiliations” and “conflicts of interest,” what each researcher typically eats for breakfast every day. You’d find out a lot more about “affiliations” and “interests” from that information than from anything else.)

And so there is this: Meat and fat intake and colorectal cancer risk: A pooled analysis of 14 prospective studies. It’s an abstract from the Proceedings of the American Association of Cancer Research, from back in 2004. It found:

Greene’s study found that a higher calorie low-carb diet resulted in more weight loss than a lower-calorie low-fat diet. I’m not arguing about what this study might prove about diets in general, so back off, all you folks out there foaming at the mouth to pick it apart. Truth is, you can’t really critique it, because it never got published.

Another study that almost didn’t make it out of the gate concluded that:

In a nutshell, Daisy Zamora found that black participants with a higher Diet Quality Index (according to the Dietary Guidelines for Americans) gained more weight over time than whites (with either a higher or lower Diet Quality Index). More surprisingly, these black participants also gained more weight over time than blacks with a lower Diet Quality Index.

Again, I’m not arguing the strengths or shortcomings of this research. The part of the story that matters here is that Zamora worked on this study as part of her PhD research at UNC-Chapel Hill. She found a tremendous amount of resistance to her findings, to the extent that she was counseled to “redo” her work without examining racial differences.

I guess that’s why, to some extent, I feel that all of the talk about “good” science vs. “bad” science in nutrition is misplaced. How do we even know that the part of “the science” we get to see fairly represents the work that has been done when the whole process is so highly politicized and ideological? How many grad students slogging away in labs or poking away at databases find things that never make it to publication because it would compromise the prevailing paradigm and their advisor’s funding (and don’t have the huevos that Zamora had to get her findings published anyway)? I feel pretty certain this doesn’t just happen in nutrition, but in nutrition it really matters to each of us, every day–and even more so to those who rely on government programs for food.

How did nutrition science become so politicized? Dietary Guidelines, I’m looking at you. When policy “chooses” a winner and a loser in a scientific controversy, things change. Science gets done differently. And when policy (dressed up as science) chooses a side in what we should/should not eat in order to prevent ostensibly preventable things like obesity and disease, well, all hell breaks loose. When we act like we “know” what foods cause/prevent disease, good health becomes entirely the responsibility of the individual. If you get fat or sick–no matter what else is going in your world or in your body–it’s your own damn fault.

How do we un-politicize nutrition science? This article from Daniel Sarewitz, “Science can’t solve it,” offers some clues. Although he’s focusing on new biotechnologies that have out-run our ethical frameworks for dealing with them, these remarks could just as well apply to diet-chronic disease science. He calls for discussions and deliberations that:

If there’s one thing we’ve got in diet-chronic disease science, it is “ongoing and inevitable uncertainties.” It’s highly unlikely that science is going to solve those uncertainties anytime soon. As for ethical frameworks, we have never given serious consideration to the ethical implications–not to mention the outright absurdity–of subjecting everyone in our diverse population to a single dietary prescription designed to prevent all of the major chronic diseases (none of which have ever been established as primarily nutritional in nature).

Until we get to these kinds of discussion, the creators of the 2015 Dietary Guidelines ought to listen to what Paul Marantz had to say back in 2010:

Many thanks to Dr. Sarah Hallberg, without whom it would have taken me another 5 years to stumble across some of these articles.

*Run one PTA meeting and try to get a half-dozen fairly intelligent, well-educated adults to coordinate plans for a yard sale, and you’ll see what I mean. We can’t agree on whether used children’s books should be 50 cents or $1–figuring out whether to ruin the health of Americans by buying off the media or silencing the scientists would be beyond any possible reckoning.

This is awesome. Thanks so much for sending this. I happened to be knee-deep in a seminar paper where I’m making an argument–from a completely different theoretical perspective–for an appreciation of the mysteries and idiosyncrasies of food-body interactions. So I can use this for sure.

So, you have learned your satire from one of the best. Though, I think maybe you have a natural talent for it.

BTW, I agree that the tipping point has happened. My television watching is mostly Comedy Central and other comedy shows. The number of jokes about eating carbs and gaining weight or vice versa is increasing. (Would my observations count as a valid epidemiology study? Please note that I have not factored out the influence of laugh tracts.) And comedians know that their jokes don’t work unless much of the audience understands and agrees with the basis of the joke. That thought makes me smile.

I’ve noticed that shift in popular discourse about nutrition as well, especially from those places that we might consider to be more “transgressive,” (although what could be more mainstream now than Comedy Central?), but it is also astounding how entrenched the orthodox view of nutrition is elsewhere. Like we are living in two different worlds.

They’re asking the BMJ to retract Nina Teicholz’s article about how the DGAC’s recommendations are not scientific. If Ms. Teicholz were a doctor or nurse or dietitian, they’d simply take her license. Thank goodness she’s not.

In the world of rhetoric, this is called “forum control.” If the piece is not “in the literature,” then it doesn’t “count.” The defenders of the orthodoxy are often in places of power that can prevent heretical views from making it into “the literature” to begin with. But if one does get through, they generally go apesh*t. Case in point here. Something very similar happened in 2013 with an article by John Abramson that made the case that statins provided no benefit for people at low risk.

Willett later faulted the study’s author, epidemiologist Katherine Flegal of the CDC’s National Center for Health Statistics, saying she failed to exclude data from smokers and the sick, two groups of generally thinner, higher-risk people that would give the overweight a relative advantage. When Flegal countered that she had adjusted for both groups and found little effect, Willett argued that properly adjusting for them was impossible.

So an epidemiologist whose claims are based on prospective studies supposed to be adjusted for smoking and pre-existing ill-health says this is impossible?

It’s an interesting article. My husband can’t get over the part about his wife; it makes him unhappy every time he thinks about it.

The whole snitfit the Harvard crowd had over the Flegal study was pretty impressive. Wrote about it here. It contains one of my favorite lines ever: “In the world of nutrition epidemiology of chronic disease, PowerPoint arrows are a scientifically-acceptable method of establishing causation.” Makes me laugh every time I think about it.

When people don’t publish inconvenient findings, it’s a betrayal of what science should be. Nina Teicholz describes the pressures that eventually forced almost everyone to agree with Ancel Keys. We haven’t quite undone that one yet.

I hope we are beyond the tipping point and that the edifice will one day suddenly collapse, but I suspect the old guard will fight to the bitter end, rather than admit they’ve been so wrong for so long.

This problem seems to be endemic with all parts of society, including the medical field. so the DGAC is merely parroting what’s happening elsewhere. A read through “Doctoring Data” by Malcolm Kendrick shows how endemic this is for medicine in general. Think your blood pressure medication has a set of long-term, randomized, controlled trials proving it reduces heart disease? Think again. “We KNOW reducing blood pressure reduces heart disease; we don’t need any stinking trials.” (Thus, if your medication reduces blood pressure, then by definition it HAS to reduce heart disease. Even if it may not.)

I used to think that the maxim that things only change once the old guard retires or dies was crazy; now, I think it’s absolutely true.

The only thing I think that’s different now is that people are rising up and not taking this type of advice anymore. When the American Diabetes Association posted the seemingly innocent question of “how’s your blood sugar today”, people came out of the woodwork to lambaste them about how their dietary policies are wrong and how low carb diets of the type advocated by Dr. Bernstein have saved them and made their blood sugar control much better. That type of outpouring can help turn the tide of non-scientific info. We’re each N=1, but together, we’re n=100 or 1,000, or 1,000,000 (or 54,000 comments to the DGAC).

Yes, the most striking thing about the recent meat-cancer issue has been the overwhelming response of “meh.”

And it is pretty exciting to see the sorts of responses we are seeing from the community of people with type 2 diabetes. Yet, there are many communities out there that may not have the resources to take matters into their own hands as much as other groups. We need to keep them in mind.

In that decade IF the ADA were actually interested in health rather than marketing and placating their sponsors they could have financed a study into this protocol. In fact they financed several studies by Mary Gannon and Frank Q Nuttall into low carb (“LoBAG”) diets and pulled their finance when they came up with the “wrong” result.

If I remember correctly the ADA were claiming something like a 1 – 2% improvement in A1c from “medical nutrition therapy” while people in their forum were routinely reporting 5 – 10% and sometimes even more reduction.

When John Buse was in charge back in 2008 they admitted that low carb diets when used temporarily and ONLY for weight reduction, and did not use less than 135g carbs/day, were acceptable. Some of their biggest sponsors pulled their money and John Buse went away.

Thank you! Nutrition “science” bears a striking resemblance to vaccine “science”, i.e., it is policy-driven, the cart before the horse. Bureaucratic inertia is a powerful force, but as rdfeinman says, “we passed some kind of tipping point.” Folks are voting with their dollars, and buying butter, and people in general, in my considered opinion, are now more skeptical of their government than I can recall in my 66 years.

Hmm. Funny you should mention vaccine science. This is one of the controversies that my students are focusing on this semester. And, again, while we may feel there’s “good” science and “bad” science in this arena as well, the real issue is how policy is going to be created in relation to not just differing views of science, but differing sets of values, privileges, etc.

The problem with vaccines is that you get immediately attacked for the mere mention that vaccines might have side effects or other issues. And I mean attacked as in they’ll take your license if you’re a doctor and demonize you if you’re not. Also, you’re up against very powerful interests (similar to the statin manufacturers) that have basically unlimited funds. Finally, there are very few or no double-blind, placebo controlled studies for vaccines and the studies there are most likely are highly biased by the people who pay for the study (the drug manufacturers). Case in point:

“It was surprising to find only one study of inactivated vaccine in children under two years, given current recommendations to vaccinate healthy children from six months of age in the USA, Canada, parts of Europe and Australia. If immunisation in children is to be recommended as a public health policy, large-scale studies assessing important outcomes, and directly comparing vaccine types are urgently required.”

I feel you there, BobM. So this is exactly the issue, though: What kind of science must be in place to authorize certain kinds of policies? Who gets to decide what these standards are? So I’m going to see if I can tackle this without alienating all both of my audience members.

In nearly every science/policy controversy there is some accepted science (or some glaring lack of accepted science, as with your point above) on either side of the issue. More & better science may address some aspects of the issue, but one of the enduring lessons of science and technology studies is that determined critics will find a way to pick apart any experimental evidence whose results don’t suit them. The process of “doing science” has enough built-in flaws that this is possible, as well as part of our accepted scientific norms of skepticism. It is likely we can’t count on science to end the controversy, because the controversy is not really just about the science. It’s about individual rights (can I be forced to vaccinate my kid?), public health (by what authority and in what situations can public health officials “force” vaccinations?), a right to public education (if I don’t want to vaccinate my kid, can my kid be denied public education?)–and so on. Policies that we enforce to “solve” a problem–mandatory vaccination for all public school kids to prevent outbreaks of childhood diseases–may not, in fact solve the problem (if parents remove their kids from public school, and those kids still go to Chucky Cheez).

Beyond all of that, there has to be a way for us (as you have illustrated so well) to question the status quo without being labeled crazy fringey nutcases. I think vaccinations to prevent common childhood illnesses that can have devastating effects are important public health measures. All of my kids got all of their vaccines on schedule without a hitch. BUT, that does not mean that our vaccine protocols and schedules can’t be questioned–and that the science behind them is beyond interrogation or reproach. To claim that (despite my own choices regarding my own children) would be to suggest that we currently have all the answers that we will ever have about this issue–and I simply don’t think science works that way.

So the question that my class will have to answer is, given the uncertainty of the science right now–and the values at play in this controversy–how do we make policy? This is the same question that must be applied to nutrition.

I think that was very well articulated. I think what happens is that everything becomes made to be too simple, and “people” (whoever they may be, the CDC, DGAC, AHA, etc.) select a “right” answer and stick to it, regardless of what happens. Since that answer has been selected, all the money is placed on proving that answer, and no money goes to disproving that answer (which is exactly the opposite of the scientific method). And since “experts” have made these recommendations, you can’t ever question them, and for really political items such as vaccinations (or statins or blood pressure medication or flu vaccinations), you could be viciously attacked for doing so.

A case in point is BMI. Do you know how 30% by BMI was selected as being “obese”? Was this based on studies where one could see that at 30% BMI, “disease” skyrocketed upward? No, instead it was picked out of hat. The simply selected it based on no data whatsoever. And, many studies have indicated that being overweight or in the first category of obesity is healthier (in terms of years lived) than being “normal” and especially “underweight”. But once that “30%” was selected, it can’t be deselected, and all the money goes into “proving” it’s correct (even when many studies indicate it’s not). (And note that both BMI and 30% are easy to calculate, thus being very simple — if completely useless and most likely wrong.)

The difference between nutrition and vaccination is that nutrition has some money to study the opposite theory. There are many studies (actual randomized controlled trials) now indicating that low carb is better than low fat in pretty much every way. With vaccinations, since everyone “has” to be vaccinated to “save lives”, you really can’t have a randomized, controlled trial (at least for childhood diseases). And if you do have a randomized, controlled trial, it’s run by the vaccine manufacturers. That’s always bad.

But this is endemic to medicine. How many RCTs have been done to prove stents (or bypass surgeries) are better than doing nothing? Or how many RCTs to prove blood pressure medication actually causes fewer heart attacks? We “know” stents (or bypasses or blood pressure medication or statins or…) are “life saving” and not doing them means you’re “killing people”.

Certainly policy is an issue, and a complex one at that. But when the overwhelming impetus is that something “save lives” (even without direct evidence it actually does that), it’s going to be an uphill battle. You can make the policy (with your students), but you probably can’t change it, particularly if the policy is political.

The main difference between policies and personal medical care is that you can refuse the latter; in many cases, policy provides many more constraints.

In my class, what I hope to do is to sensitize my students to these issues so that when they are in positions of leadership in jobs or in the community, they can do a better job than we’ve done in the past.

Quite! The Revolution has been bottom up, driven by patients and a small but increasing number of clueful doctors. There is now a huge body of research hidden in plain sight on PubMed but doctors and especially dieticians are not being told it is there. My GP who is being paid to be a “diabetes expert” has never heard of Gerald Reaven or Ron Krauss, let alone Richard Feinman, Eric Westman, Stephen Phinney, Jeff Volek or even Richard Bernstein, let alone Joseph Kraft, John Yudkin, Peter Cleave, Weston A Price. . . Conventional Wisdom is becoming ever more entrenched, I suspect Big Money is behind the fightback.

No doubt healthcare professional education is the next big step. My nephew recently graduated from medical school. He was taught that low-carb diets are the most effective nutritional therapy for type 2 DM. Then he was told not to bother with it, since people “won’t” follow it. Sigh. I’m seeing shifts among RDs here in NC and elsewhere, driven (imho) by the competition from “alternative” nutrition practitioners who have no problems with carbohydrate reduction as an intervention. But it is true that we are not taught about this in our RD training.

If people are given the right advice and don’t take it, the system has done its job. When the system gives stupid advice it betrays its purpose. Many diabetics would follow clear advice, particularly when they saw it worked. others would quickly follow.

I think the “people won’t follow it” thinking comes from the same sort of “written by the victors” thinking behind nutrition epidemiology. Of course people who follow the DGA diet prescription have better health outcomes than those who don’t; these are the same people who would have better health outcomes if the federal public health prescription said wear a pink bow tie. These folks would wear the pink bow tie (and not smoke or drink too much; watch their weight; take a multivitamin; exercise; get regular checkups; and call their mother’s on Mother’s Day), because that’s what you are supposed to do.

If doctors prescribed carbohydrate reduction, endorsed it as a helpful means of controlling blood sugar, and supported their patients who wished to do their best to comply–well, I’m thinking, many people might just actually follow a reduced carb diet without too many problems.

This discussion reminds me of the time Dr. Bernstein discussed diabetes with a guy from the ADA on dLife. The guy said that he more or less agrees that low carb is the best way to control diabetes, but he does not recommend it to his patients. Because the diet is almost impossible to follow, he wants to protect his patients from the psychological damage of failing to stick to the diet. I went ballistic. Commenting to that guy, what about the psychological damage done by going blind or having to go to dialysis several times per week for your shortened life? And further who died and made you God? You should never judge a person’s will power, just give them the facts, period.

Amen. Part of the whole Dietary Guidelines phenomenon has been an expansion of a class of nutrition experts who “do our knowing for us,” because so much of what is supposed to be “known” about nutrition couldn’t be known without experts. But, seems to me, this encourages “expert creep” (and no, I don’t mean David Katz). If I know what you should be eating, maybe I know what you are thinking and feeling as well.